Clinical Care Partner

Compassus•Jacksonville, FL

2d•Onsite

About The Position

The Clinical Care Partner is responsible for coordinating safe, efficient, and patient-centered transitions of care for hospitalized patients. This role evaluates patients for appropriate post-acute home-based care services and supports timely, high-quality discharge planning in collaboration with physicians, case management, patients, families, and post-acute providers. The position focuses on improving patient outcomes, reducing length of stay and readmissions, and ensuring patients receive the right care in the right setting at the right time. This is an in-person role requiring bedside engagement, interdisciplinary collaboration, and active participation in discharge planning workflows. This role will support Southside Hospital. Monday - Friday, 8am - 5pm.

Requirements

Associate’s degree in Nursing, Health Sciences, or related field. Alternatively, equivalent degree and healthcare experience.
Active and unencumbered RN, LMSW, LCSW, or LICSW licensure.
Current CPR certification.
Compliance with all JV hospital partner occupational health requirements.
Ability to read, analyze, and interpret clinical documentation, professional journals, technical procedures, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals.
Ability to effectively present information and respond to questions from leaders, teammates, patients, families, and external parties.
Strong written and verbal communications.
Ability to understand, read, write, and speak English.
Articulates and embraces hospice philosophy.
Ability to manage multiple projects simultaneously and meet deadlines.
Ability to design accessible and inclusive learning experiences for a diverse workforce.
Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds.
Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus.

Nice To Haves

Bachelor’s degree in nursing, Health Sciences, or related field.
2–3 years of experience in care coordination, discharge planning, or healthcare services.
Hospital, home health, hospice, or post-acute care experience.
Experience working with EMR systems (ie: Epic) and referral platforms.

Responsibilities

Evaluate patients for appropriateness for home-based and post-acute care services based on clinical, functional, psychosocial, and environmental factors
Review inpatient referrals and prioritize patients using clinical judgment and predictive analytics tools
Collaborate with physicians and care teams to support appropriate level-of-care decisions
Identify patients appropriate for value-based post-acute care services
Coordinate and facilitate timely, safe, and appropriate hospital discharge planning
Develop and implement individualized transition-of-care plans aligned with patient needs and clinical goals
Partner with physicians, advanced practice providers, case management, and nursing teams
Arrange post-acute services including home health, hospice, durable medical equipment, medications, and follow-up care
Ensure accurate and timely patient handoff to post-acute providers
Educate patients and families on post-acute care options, care expectations, and available services
Provide bedside education to support informed patient choice and shared decision-making
Educate hospital staff and clinical stakeholders on post-acute pathways and referral processes
Support understanding of value-based care principles and appropriate site-of-care selection
Serve as liaison between hospital teams and post-acute providers to support timely referrals and placements
Maintain strong relationships with physicians, case management, nursing teams, and discharge planners
Participate in interdisciplinary rounds, discharge planning meetings, and care coordination discussions
Strengthen referral network partnerships to improve access and placement efficiency
Identify patients appropriate for hospice and/or General Inpatient (GIP) level of care
Coordinate hospice evaluations, eligibility determinations, and admission processes
Support end-of-life transitions with clinical urgency and patient-centered communication
Ensure alignment with hospice eligibility requirements and physician certification processes
Document all care coordination activities accurately and timely in the electronic medical record
Manage referrals through designated hospital and post-acute referral systems
Utilize clinical decision-support tools and predictive analytics platforms
Maintain accurate tracking of referrals, outcomes, and transitions across systems
Support VBE performance goals and care coordination strategy
Contribute to key performance indicators including: Hospital Length of Stay (Observed-to-Expected Ratio), Hospital Readmission Rates, Hospital Mortality Rates, Timely Initiation of Care, Referral-to-Admit Rate, Referral Quality and Documentation Accuracy
Participate in quality improvement and workflow optimization initiatives
Support organizational initiatives to improve post-acute network performance and patient outcomes